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1. JAG Joint Advisory Group on
General Practice and Population Health
Smoking, Nutrition,
Alcohol and Physical
Activity (SNAP)
Framework for
General Practice
Integrated approaches to supporting the
management of behavioural risk factors of
Smoking, Nutrition, Alcohol and Physical
Activity (SNAP) in General Practice
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GENERAL PRACTICE
PARTNERSHIP
ADVISORY COUNCIL
2. Smoking, Nutrition,
Alcohol and Physical
Activity (SNAP)
Framework for
General Practice
Integrated approaches to supporting the
management of behavioural risk factors of
Smoking, Nutrition, Alcohol and Physical
Activity (SNAP) in General Practice
This document has been prepared by the Joint Advisory
Group on General Practice and Population Health
June 2001
4. Contents
Introduction 1
Burden of disease and injury 1
Aim of the SNAP Framework for General Practice 3
Development of the SNAP Framework 3
Description of SNAP 4
The evidence base 4
SNAP implementation 5
Further information 6
Abbreviations used in the Framework 7
Outcome 1: Organisational structures and roles 8
Objective 1: To strengthen the support provided by organisational structures
(GP organisations, government and non-government organisations)
to encourage integrated approaches to SNAP risk factor management
Outcome 2: Financing systems 11
Objective 2: To increase the availability of appropriate remuneration and incentives
to support sustainable SNAP risk factor activity in general practice
Outcome 3: Workforce planning, education and training 12
Objective 3: To increase the numbers of GPs and practice staff who have knowledge
about, and relevant skills to implement evidence based integrated
approaches to risk factor management
Outcome 4: Information management and information technology
– clinical support tools, data collection and analysis 14
Objective 4: To improve clinical support to GPs for SNAP risk factor identification
and management through:
• clinical decision support tools;
• patient registers;
• patient recall and monitoring systems;
• data collection and analysis systems to assist GPs with clinical care of
patients and to enable monitoring of targets for each risk factor at all levels.
Outcome 5: Communication, community awareness and
patient education 16
Objective 5: To raise awareness amongst GPs, their patients and the broader
community about the impact of the risk factors of tobacco, alcohol,
physical inactivity and poor nutrition on health status and about the
role GPs (and other primary care providers) can play in working with
patients and carers to prevent and manage these risk factors.
iii
5. Outcome 6: Partnerships and referral mechanisms 18
Objective 6: To encourage increased networks of health professionals, including
community support professionals, to work together with patients and carers
to support risk factor behaviour change.
Outcome 7: Research and evaluation 20
Objective 7: Facilitation of research into appropriate evidence based interventions,
data collection and evaluation of integrated approaches to SNAP risk
factor identification and management in general practice
List of partners for SNAP Framework 23
List of figures
Figure 1: Attributable risk factor DALYs as a proportion (%) of total DALYs
(AIHW, 2000) 1
Figure 2: DALY burden of disease and injury as a proportion (%) of total DALYs
(AIHW, 2000) 2
Figure 3: SNAP risk factors and the National Health Priority Areas 2
iv
6. Introduction
The following Smoking, Nutrition, Alcohol and Physical Activity (SNAP) Risk Factor Framework
for General Practice is an initiative of the Joint Advisory Group (JAG) on General Practice and
Population Health. JAG consists of members of the General Practice Partnership Advisory Council
(GPPAC) and nominees of the National Public Health Partnership (NPHP).
The SNAP Framework has been developed by JAG, in conjunction with Chairs of National
Population Health Strategies, to guide the implementation of integrated approaches to behavioural
risk factor modification in general practice focusing on smoking, nutrition, alcohol and physical
activity (SNAP). A wide range of patients in any practice may present with one or more of these
risk factors. The SNAP Framework develops a system-wide approach to supporting general practice
in the management of these behavioural risk factors with patients.
Burden of disease and injury
The SNAP risk factors have been identified as significant contributors to the burden of disease in
Australia, including all the National Health Priority Areas. Each of the SNAP risk factors is
responsible for large amounts of ill health, suggesting that substantial health gains can be expected
from effective public health interventions to address these risk factors.
Figure 1 presents data from The Burden of Disease and Injury in Australia (Australian Institute of
Health and Welfare, 2000), on the proportion of total burden of disease and injury attributed to the
SNAP behavioural risk factors and related physiological risk factors (eg. overweight and obesity,
hypertension, high blood cholesterol).
Figure 1: Attributable risk factor DALYs as a proportion (%) of total DALYs (AIHW, 2000)
12.1
Tobacco 6.8
Physical activity 6
7.5
Hypertension 5.1
5.8
Alcohol harm 6.6
3.1
-2.4
Alcohol benefit -3.2
Overweight and obesity 4.4 Male
4.3
Female
Lack of fruit/veg. 3
2.4
High blood cholesterol 3.2
1.9
Illicit drugs 2.2
1.3
Occupation 2.4
1
Unsafe sex 1.1
0.7
-5 0 5 10 15
1
7. Accumulated evidence demonstrates the clear association between the prevalence of SNAP-related
risk factors, and the risks of developing disease or sustaining injury. Figure 2 shows the DALY
burden of disease and injury as a proportion of total DALYs for the leading causes of morbidity and
mortality, which (with the exception of dementia) have a causal link with the SNAP risk factors.
These links are set out in Figure 3.
Figure 2: DALY burden of disease and injury as a proportion (%) of total DALYs (AIHW,
2000).
Ischaemic heart disease 13.6
11.1
Stroke 4.8
6.1
Chronic obstructive pulmonary disease 4.2
3.2
2.7
Depression 4.8
Lung Cancer 4.5
2.6
2.5 Male
Dementia 4.7 Female
Diabetes Mellitus 3
3
Colorectal cancer 2.7
2.7
2.1
Asthma 3.1
Osteoarthritis 1.7
2.9
0 2 4 6 8 10 12 14 16
Figure 3: SNAP risk factors and the National Health Priority Areas
Nutrition
COMMON
Physical Activity CVD
Alcohol Diabetes
Smoking Cancer
Hypertension Mental Health
High blood cholesterol Injury
Overweight and obesity Asthma
The prevalence of the SNAP behavioural risk factors varies amongst different groups within the
population. For example, a greater proportion of people in low socioeconomic groups are regular
smokers than are people from higher groups. Similarly, the percentage of people who lead sedentary
lifestyles is higher amongst those who did not complete secondary schooling than those with tertiary
qualifications.
2
8. Aim of the SNAP Framework for General Practice
The SNAP Framework aims to improve health outcomes in the community by supporting and
enhancing the role that general practice plays in increasing levels of good nutrition and physical
activity and decreasing smoking prevalence and alcohol misuse. The SNAP Framework represents
a system wide approach to behavioural risk factor identification and management and it acknowledges
the importance of socio-economic factors in behavioural risk factor modification. The initiative
targets consumer awareness of the links between behavioural risk factors and chronic disease and
highlights the role of the general practitioner (GP) as an agent for supporting behavioural change.
The SNAP Framework is intended to reduce the level of competing pressures that GPs work under.
It provides an opportunity for combining general practice initiatives by the National Population
Health Strategies, resulting in, for example, availability to GPs of streamlined evidence based
information, or patient information materials covering smoking, alcohol misuse, nutrition and
physical activity. The SNAP Framework proposes a collaborative means of advancing common
risk factor interests in the general practice setting, while maintaining policy autonomy within all of
these Strategies.
Integration of effort using the SNAP Framework can streamline general practice participation in
population health by:
• maximising common prevention methods;
• providing practical support tools; and
• reducing the amount of paper and electronic information provided to GPs relating to individual
strategies in isolation.
The aims of the SNAP Framework are consistent with and support implementation of Preventing-
Chronic Disease: A Strategic Framework, which has been developed by the National Public Health
Partnership and endorsed by the Australian Health Ministers’ Advisory Council. The SNAP
Framework also supports the Australian Health Ministers’ commitment to greater collaboration in
the primary health care and community care sectors. A possible extension of the SNAP initiative,
beyond the general practice setting, would be to develop a complementary systematic and integrated
approach to behavioural risk factor management for broader primary health care and community
care settings. This would substantially strengthen the capacity of the health sector to tackle prevention
and management of chronic disease, and facilitate the building of clinical partnerships between
health professionals.
Development of the SNAP Framework
In January 2001 a draft SNAP Framework was widely circulated to stakeholders in general practice,
allied health, population health, government and non-government organisations (NGOs) including
those with a focus on the health of Aboriginal and Torres Strait Islanders. Comments and input
were sought and a substantial number of responses were received. Many valuable suggestions were
made about the structure of the Framework, its scope, priorities, timeframes, partners and individual
objectives and strategies.
Focus Groups were held in February-March with practicing GPs, who were not members of GP
organisation committees or structures, to test what the implementation of the Framework would
mean to them on a practical level.
The Framework received further consideration during the JAG National Symposium on General
Practice and Population Health convened in Sydney in March 2001. At the Symposium there was
broad agreement to a Consensus Statement between GPPAC and the NPHP on the role general
practice can play in contributing to population health outcomes. Symposium participants contributed
3
9. to the development of an associated Framework for Action. The roles and principles outlined in the
Consensus Statement provide a context and basis for the SNAP Framework and SNAP forms a
specific example of the broader JAG Framework for Action.
Description of SNAP
The SNAP Framework suggests actions against seven broad outcome areas:
• organisational structures and roles;
• financing systems;
• workforce planning, education and training;
• information management and information technology;
• communication, community awareness and patient education;
• partnerships and referral mechanisms; and
• research and evaluation.
Roles and activities are across five levels:
• GP/patient consultation;
• GP practice;
• Division of General Practice and local community;
• State level; and
• National level.
These roles and activities represent an array of possible strategies at different levels and are not
intended to indicate that all GPs or all Divisions must undertake all of the suggested strategies.
Rather the strategies are intended as a range of possibilities giving Divisions and GPs the flexibility
to determine which strategies to pursue, while promoting integration of effort between all levels.
The SNAP Framework also provides a structure for increasing integration across the primary health
care sector. It recognises that GPs do not work in isolation from others, and that the SNAP behavioural
risk factors are complex in both their origin and maintenance. Hence risk factor management or
modification requires a comprehensive, consistent, educative and supportive approach.
In recognition of the time constraints experienced by most GPs, greatest gains can be made when
GPs work in partnership with other health professionals and providers. GPs can then focus on
identification and ongoing monitoring of these risk factors, rather than directly implementing
behavioural change programs other than those requiring brief intervention only.
The evidence base
The SNAP Framework is based on available evidence of cost-effective interventions within general
practice for the management of the four risk factors, on current initiatives within Divisions of
General Practice and the relevant National Population Health Strategies. Development was also
informed through the consultation process described above.
The Department of General Practice and Public Health, Melbourne University was commissioned
to report on the relative effectiveness of population health interventions in the general practice
setting. While the final report is yet to be released, the available research indicates that at the
organisational levels (the practice, Division, the state and national levels), there are potential benefits
from combining risk factor approaches.
While the evidence base to date regarding concurrent multiple behaviour change with individuals
is narrow in scope, it will be up to the clinical decision making of individual GPs to assess the
potential impact of combined approaches in relation to individual patient management.
4
10. The impact of integrated strategies in the Australian context will need to be monitored and evaluated
over time to determine effectiveness and the evidence base for future activity in this area.
SNAP implementation
The SNAP Framework forms part of the Framework for Action developed to implement the JAG
Consensus Statement. The JAG National Symposium highlighted a number of areas of future activity
to enhance the population health role of general practice and JAG will consider these as part of its
future work program. Some of these could have bearing on implementation of the SNAP Framework
as will other on-going initiatives in general practice such as support for computerisation.
Some groups within the Australian population bear a disproportionate burden of disease and have
higher levels of risk factor behaviours than the population in general, in particular Aboriginal and
Torres Strait Islander people, people on low incomes and people living outside metropolitan areas.
Implementation of the SNAP Framework should have a particular focus on these priority population
groups.
Several activities in the SNAP Framework make specific mention of approaches that GPs or Divisions
of General practice might take to address the health needs of disadvantaged groups. However,
addressing the broader social and economic causes of health inequality is outside the scope of the
SNAP Framework. GPs operating outside comprehensive primary health care settings can be limited
in what they are able to do to address the health needs of disadvantaged people in the local community,
for instance, because people may not attend general practice for preventive health care for cultural
or other access reasons. Two initiatives at the national level that will have an impact on how general
practice may address health inequality in the future are:
• the Health Inequalities Research Collaboration, which aims to enhances Australia’s knowledge
on causes of, and effective responses to, health inequalities. One of three research networks
being established is in the area of primary health care; and
• the Action on Health Inequalities in General Practice project of the Royal Australian College of
General Practitioners. This project intends to strengthen policies within general practice
organisations that can address the link between social and economic disadvantage and health
outcomes.
There is evidence that health investment at critical life stages can significantly improve mental and
physical health in later life. The pre and post-natal periods are critical times for laying the foundations
for adult health. Another important intervention point is mature age (45-55) where identification
and management of risk factors can limit the burden of chronic disease in later life and promote
healthy ageing. The importance of intervening at critical life stages, which will be different between
population groups, should be a factor for consideration in the implementation of SNAP initiatives.
The SNAP Framework is built around communication and collaboration at the local and regional
levels between GPs and allied health providers and others in the primary health care sector.
Consultations on the SNAP Framework have raised concerns about lack of availability of allied
health or other primary care providers and about costs to patients of private practitioners. The
SNAP Framework cannot address these broader access issues. However its implementation needs
to be seen in the context of other initiatives in the primary care sector, particularly Australian
Health Minister’s agreement to jurisdictional action to strengthen the primary health care sector
including its role in population health. The draft discussion paper Preventing Chronic Disease: A
Strategic Framework prepared by the NPHP and recently endorsed by AHMAC, recommends the
need to strengthen the role of prevention in the health care system and to improve systems of care
for those with existing chronic disease. Development and implementation of the SNAP framework
is identified as a priority action that can support this agenda.
5
11. The SNAP Framework should not be taken as indicating that Divisions or practices would be solely
responsible for implementing strategies, nor does it imply any funding commitment by any party. It
recognises that Divisions have flexibility under current Outcome Based Funding (OBF) Agreements
to undertake population health activities as they see fit. The Framework could, however, assist
Divisions either within current or future OBF Agreements.
A working group has been formed to prioritise actions under the SNAP Framework and to make
recommendations to progress implementation. This group comprises a range of views such as general
practice, consumers, the National Public Health Strategies associated with Smoking, Nutrition,
Alcohol and Physical activity; Aboriginal and Torres Strait Islander peoples, a representative of a
State Government and a representative of the National Vascular Disease Prevention Partnership (an
alliance of the National Heart Foundation, Diabetes Australia, Australian Kidney Foundation and
the National Stroke Foundation). The working group recognises that roll out of the SNAP Framework
will take place over 5-10 years with early priority achievements planned for the first 12 months.
Further information
If you would like more information on the work of the Joint Advisory Group on General Practice
and Population Health please contact Professor Mark Harris on 02 9385 2511. If you would like
additional copies of the SNAP Framework or further information on the implementation process,
please contact Rachel Balmanno, Director, Healthy Ageing and Chronic Disease Prevention
Section, Population Health Division, Australian Government Department of Health and Ageing
on 02 6289 8534 or email the snap@health.gov.au. Copies may also be downloaded from http://
www.health.gov.au/pubhlth/about/gp/
Professor Mark Harris
Chair, Joint Advisory Group on General Practice and Population Health
6
12. Abbreviations used in the Framework
ACCHS Aboriginal Community NACCHO National Aboriginal
Controlled Health Services Community Controlled
ADGP Australian Divisions of Health Organisations
General Practice NGO Non-Government
AGDHA Australian Government Organisation
Department of Health and NHMRC National Health and
Ageing Medical Research Council
AIHW Australian Institute of NHPA National Health Priority
Health and Welfare Area
BEACH Bettering the Evaluation NHPAC National Health Priority
And Care of Health Action Council
CME Continuing Medical NIS National Information
Education Service
CHF Consumers Health Forum NPHP National Public Health
DALY Disability Adjusted Life Partnership
Years NSCWG National Strategies
Division Division of General Coordination Working
Practice Group
EBG Evidence Based Guidelines PHD Population Health Division,
Australian Government
EPC Enhanced Primary Care Department of Health and
Initiative Ageing
GP General Practitioner PHERP Population Health
GPCG General Practice Education and Research
Computing Group Program
GP MOU General Practice PIP Practice Incentives
Memorandum of Program
Understanding RACGP Royal Australian College of
GPPAC General Practice General Practitioners
Partnership Advisory Red Book Guidelines for Preventative
Council Activities in General
Green Book Putting Prevention into Practice (5th Ed, RACGP
Practice (1st Ed, RACGP, 2001, in print)
1998) SBO State Based Organisation of
HIC Health Insurance Divisions of General
Commission Practice
IM/IT Information Management/ SNAP Smoking, Nutrition,
Information Technology Alcohol, Physical activity
JAG Joint Advisory Group on
General Practice and
Population Health
7
13. Outcome 1: Organisational structures and roles
Objective 1: To strengthen the support provided by organisational structures
(GP organisations, government and non-government
organisations) to encourage integrated approaches to SNAP risk
factor management
Suggested activities or roles
GP consultation
GP practice
1.1 Practices encourage GPs and practice staff to be aware of and use available training, incentives
and other supports to facilitate SNAP risk factor activity.
Division and community level
1.2 Divisions develop structures and mechanisms to support the objectives and strategies of the
SNAP framework in the following outcome areas:
• financing systems;
• workforce planning, education and training;
• information management and information technology;
• communication, community awareness and patient education;
• clinical partnerships and referral mechanisms; and
• research and evaluation.
1.3 Divisions develop structural arrangements to facilitate collaborations and cross-sectoral
linkages with other stakeholders/partners to support the objectives of the SNAP framework,
for example:
• divisions Business Plans and public documents include cross-sectoral linkages and
collaboration with stakeholders as a specific value;
• divisions develop structures to support consumers and consumer groups work
collaboratively with GPs and practices on SNAP risk factor modification strategies;
• divisions facilitate coordinated approaches and partnerships at the local level with
relevant agencies and local service providers to meet the needs of the local community
and GP populations, especially of Aboriginal and Torres Strait Islander populations
and other specific population groups and geographical areas;
• divisions establish regional collaborations with other Divisions, SBOs, NACCHO
Affiliates and member services and population health programs/services to:
– develop common understanding of population health in the primary care context;
– develop common approaches to risk factor modification;
– demonstrate that Aboriginal community control is a key requirement for Aboriginal
health program implementation; and
– advocate especially on behalf of disadvantaged groups to address risk factor health
determinants at the regional level.
8
14. 1.4 Divisions work with practices to identify and resolve barriers to uptake of SNAP strategies,
eg through practical assistance to implement the “Green Book”, and establish data
management systems.
State level
1.5 Establish state level collaborations between State Governments, SBOs, NACCHO affiliates,
state based NGOs, GP and population health academic departments to support the SNAP
objectives and strategies through activities such as:
• development of policies and protocols; and
• engaging in joint regional planning processes.
National level
1.6 Develop national policies and strategies explicitly encouraging linkages and communication
networks at all levels between GPs and GP organisations, allied health professionals, ACCHSs
and their affiliates and national peak body, and the population health sector.
1.7 Ensure that JAG, NPHP, GPPAC structures and workplans reflect and facilitate risk factor
activity.
1.8 Ensure consolidation of effort at the national level through consistency in the primary health
care initiatives of Australian Health Ministers and the objectives and activities of the SNAP
Framework.
1.9 Ensure that the development or modification of national initiatives to support integrated risk
factor action at Division and practice levels, eg PIP, accreditation, GP education policies.
1.10 AGDHA takes a leadership role with SBOs and Divisions to develop capacity for Divisional
support to practices on behavioural risk factor modification.
1.11 National public health strategies for smoking, nutrition, alcohol, physical activity (SNAP)
collaborate to develop integrated approaches applicable to the general practice setting.
9
16. Outcome 2: Financing systems
Objective 2: To increase the availability of appropriate remuneration and
incentives to support sustainable SNAP risk factor activity in
general practice
Suggested activities or roles
GP consultation
2.1. GPs increase use of payment and incentive mechanisms that reward SNAP risk factor activity.
2.2. GPs use EPC Medicare items, where appropriate, to engage with local primary health
providers in case conferences and care planning.
GP practice
2.3. Practices make use of PIP payments, where appropriate, and other payments and incentives
for SNAP risk factor interventions.
2.4. Practices provide information to GPs about available incentives to support SNAP risk factor
activity.
Division and community level
2.5. Divisions work with practices and GPs or develop joint approaches to:
• develop structures that support payments and incentives to GPs to undertake SNAP
risk factor activity;
• inform GPs and practices of available payments and incentives for SNAP risk factor
activity; and
• train GPs and practice staff in how to apply for incentives and practice payments,
including making use of EPC Medicare items to engage with local primary care
providers, where appropriate, in case conferences and care planning.
State level
2.6. SBOs develop structures to support payments and incentives to GPs to undertake SNAP risk
factor activity.
National level
2.7. Encourage shaping of current financing structures to further support risk factor population
health activity in general practice including (where appropriate) EPC Medicare items, PIP
including for clinical auditing and IM/IT, CME and other incentives for training, practice
accreditation, Divisional and SBO funding, and exploration of other funding mechanisms
such as sessional payments and practice nurses.
2.8. Ensure general practice funding mechanisms and incentives, including Outcomes Based
Funding, are particularly tailored towards evidence based and culturally appropriate SNAP
risk factor related and other population health activity for high-risk populations such as
Aboriginal and Torres Strait islander people.
11
17. Outcome 3: Workforce planning, education and
training
Objective 3: To increase the numbers of GPs and practice staff who have
knowledge about, and relevant skills to implement evidence based
integrated approaches to risk factor management
Suggested activities or roles
GP consultation
3.1. GPs make use of training, workforce planning and other supports to increase evidence based
SNAP risk factor activity with their patient population especially engagement in self-
management approaches to risk factor modification.
GP practice
3.2. GPs and other practice staff participate in education and training programs such as PHEC
and other risk factor training programs offered by Divisions to increase skills in risk factor
management, brief interventions, Aboriginal health, behaviour change theory, chronic disease
self management.
3.3. GPs participate in clinical audit processes to increase skill levels in, eg in PHEC modules
and SNAP risk factor behaviour change strategies.
Division and community level
3.4. Divisions collaborate with GP and population health academic units, local population health
experts and primary care providers to develop or adapt locally relevant SNAP risk factor
training materials and programs, ensuring appropriate Division staff themselves are trained
in and understand population health approaches to risk factor management.
3.5. Divisions facilitate and collaborate to deliver population health risk factor training programs
for GPs, practice staff and where possible other primary care providers and actively encourage
their attendance. Topics could include:
• implementation of risk factor EBG;
• PHEC modules;
• priority needs of high risk populations such as Aboriginal and Torres Strait Islander
people;
• how to apply for incentives and practice payments;
• systems and structures, eg implementation of the “Green Book”, to support consistent
messages on risk factors being provided to patients;
• the application of evidence based behaviour change strategies in relation to individual
risk factors; and
• the collection and use of data by general practices to enhance clinical practice and for
planning, surveillance, monitoring, and evaluation.
12
18. State level
3.6. SBOs,Promoting healthy exercise State Governments, population health organisations, NGOs
and State affiliates of NACCHO collaborate in the development and implementation of state
specific training and education policies and programs to facilitate Divisional training on
SNAP risk factors.
3.7. Identify good practice models in risk factor management/modification at Division and practice
levels for communication and uptake, with associated training, by other practices or Divisions.
National level
3.8. Support strategies to encourage uptake of the PHEC program by GPs and other primary care
providers.
3.9. Ensure consistency between national education programs that impact on risk factor
management and the PHEC program.
3.10. Work with national education and training bodies such as RACGP, NACCHO, GP academic
departments and the ANAPHI network to include risk factor modification strategies in medical
undergraduate and post graduate curriculum and vocational training and to specifically include
experience in risk factor modification in clinical attachments.
13
19. Outcome 4: Information management and
information technology – clinical
support tools, data collection and
analysis
Objective 4: To improve clinical support to GPs for SNAP risk factor
identification and management through:
• clinical decision support tools;
• patient registers;
• patient recall and monitoring systems;
• data collection and analysis systems to assist GPs with clinical
care of patients and to enable monitoring of targets for each
risk factor at all levels.
Suggested activities or roles
GP consultation
4.1 GPs, with the involvement of patients, utilise developments in information technology such
as clinical decision support tools and patient recall systems, to enhance consultations and
evidence based clinical practice in SNAP risk factor management.
4.2 GPs make use of electronic tools to provide patients with personalised intervention plans
and information relating to one or more risk factors.
4.3 GPs with agreement of patients, routinely record information (electronic or hard copy) relating
to the risk factor status of patients to enable clinical review and auditing and to assist GPs in
patient care.
4.4 GPs refine clinical practice in risk factor management according to the outcomes of clinical
audit processes.
GP practice
4.5 Practices install, train staff in use of, and apply, electronic population health support tools
and data and monitoring packages that are customised to enhance all aspects of general
practice including SNAP risk factor management, drawing on support from Divisions or
other support structures.
4.6 Practices take advantage of incentives and training opportunities available for GPs and practice
staff on the use of software packages and systems, including data collection.
Division and community level
4.7 Develop IM/IT structures and strategies (including incentives and training) at Division level
to support and encourage use of electronic data, EBG, and decision support tools in general
practice for SNAP risk factor management in collaboration, where relevant, with other primary
care providers.
14
20. 4.8 Identify data needs at Division level and develop (or adapt) population health electronic
data management systems and packages that will assist GPs in clinical patient care and meet
Divisional planning and other data requirement needs.
4.9 Divisions work with interested practices to develop data systems to support systematic
population health activity, eg trials of voluntary patient registers.
4.10 Establish Division based training programs on the collection and use of data that meet the
identified needs of general practices (and other primary care providers) to enhance clinical
practice and assist in audit, monitoring, surveillance, research and evaluation of SNAP risk
factors.
State level
4.11 Facilitate the development of policies and strategies at the state level to encourage use of
electronic data and decision support tools in general practice which comply with state data
requirements, eg for surveillance and screening at state, regional and practice levels.
National level
4.12 AGDHA takes a lead role in collaboration with the GPCG and other relevant groups to
develop common architecture and a suite of electronic support tools to support SNAP risk
factor identification and management. Elements of the package to include:
• access to EBG and decision support tools, eg for the risk factors and the “Red Book”
and “Green Book;
• provision of personalised patient information on the risk factors;
• capacity for data collection that is consistent with other GP data collection
methodologies;
• tools for implementing population health approaches such as recall systems,
identification of risk categories, and monitoring;
• capacity for electronic service directories that can be developed and used at Division/
practice levels;
• compliance with existing systems and software; and
• relevance to and ease of use in the clinical consultation.
4.13 Encourage future IM/IT initiatives to reflect the multidisciplinary approach to population
health activities through collaboration with relevant primary care providers and peak NGO
organisations.
4.14 Develop a national education strategy to support and encourage SNAP risk factor (and other
population health) data and electronic support systems in general practice.
15
21. Outcome 5: Communication, community awareness
and patient education
Objective 5: To raise awareness amongst GPs, their patients and the broader
community about the impact of the risk factors of tobacco,
alcohol, physical inactivity and poor nutrition on health status and
about the role GPs (and other primary care providers) can play in
working with patients and carers to prevent and manage these
risk factors.
Suggested activities or roles
GP consultation
5.1 GPs capitalise on risk factor awareness strategies to work with patients to identify risks,
increase motivation and develop individual (formal and informal) plans to address risk factors.
5.2 GPs provide patients with clinically and culturally appropriate risk factor information
materials to assist in behavioural change.
GP practice
5.3 Practice staff provide consistent evidence based information and support to patients on risk
factor management.
5.4 Practices establish systems for distributing and rotating waiting room materials (eg literature,
videos and posters that contain evidence-based information to inform patient’s choices about
behavioural risks), drawing on support from Divisions or other support structures.
Division and community level
5.5 Divisions, in partnership with other players such as Local Government, ACCHS, Aboriginal
Health Workers, other primary care providers, regional health services:
• identify local issues and community needs, hard to reach groups, and barriers to risk
factor modification strategies, eg through surveys, accessing electronic planning tools
such as HealthWIZ;
• develop or adapt nationally developed patient information material to meet the needs
of local communities, especially hard to reach groups, ensuring cultural relevance and
information on local risk factor modification programs and providers;
• develop locally applicable and culturally appropriate communication strategies
particularly targeting hard to reach groups that provide information on risk factors and
the role of GPs (and others in the primary care sector) as agents of change, eg through
local media, community groups, pharmacies and clinics; and
• develop strategies and initiatives to promote healthier environments for behavioural
change, eg concerning cigarette and alcohol sales to minors, no smoking areas, healthy
school tuckshops, fresh vegetable and fruit supplies, safe walking paths, exercise groups
etc.
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22. State level
5.6 State/Territory governments, SBOs and NGOs collaborate to develop:
• state based approaches to awareness raising about SNAP risk factors, which give
consistent advice to that provided at the national and GP practice levels and the GP’s
role in providing information and advice on risk factors; and
• marketing strategies to encourage uptake of SNAP risk factor activities by GPs and
practices.
5.7 Include consistent behavioural risk factor information on State Government and state level
NGO web-sites and in printed patient information material.
National level
5.8 Undertake focus testing with community groups to identify attitudes towards and opportunities
for enhanced risk factor identification and management in general practice.
5.9 Coordinate and consolidate social marketing strategies where possible, with advice from
relevant peak bodies, which relate to individual risk factors.
5.10 Summarise and make available to Divisions, practices and other primary care providers the
evidence of maximising the impact of practice waiting room display materials on SNAP
risk factors, and available supports to assist practices in doing this.
5.11 Develop national newsletters and educational strategies for GPs to raise awareness of SNAP
risk factor activities relevant to general practice.
5.12 Facilitate incorporation of SNAP risk factor patient information into GP electronic decision
support packages as these are developed.
5.13 Develop collaborative strategies to reach populations unable to access mainstream information
sources eg to overcome literacy, language and cultural barriers.
5.14 Ensure that consistent risk factor information is available to consumers and highlighted on
HealthInsite and other AGDHA communication channels.
5.15 National Population Health Strategies targeting SNAP risk factors collaborate to develop:
• community awareness initiatives and patient education materials that are integrated
where appropriate and are relevant to the general practice setting;
• strategies that raise community expectations to encourage patient initiated discussions
with GPs about risk factor behaviour change; and
• tools such as a self administered checklist to assist GPs routinely identify patients with
behavioural risk factors.
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23. Outcome 6: Partnerships and referral mechanisms
Objective 6: To encourage increased networks of health professionals,
including community support professionals, to work together with
patients and carers to support risk factor behaviour change.
Suggested activities or roles
GP consultation
6.1 GPs build on and make use of relationships with other primary care providers and services
to:
• refer patients to appropriate risk factor modification programs and primary care
providers;
• facilitate integrated and coordinated approaches to factor modification strategies for
individual patients; and
• develop referral and feedback mechanisms to enhance patient care and GP/provider
satisfaction with processes and outcomes.
GP practice
6.2 Encourage practice staff to promote referral of patients to appropriate programs and providers
to address SNAP risk factor modification in patients.
6.3 Ensure availability of electronic and/or hard copy directories of local community service
providers for use in GP consultations.
6.4 Establish networks and cooperative working arrangements between practices and primary
care providers, especially community nurses, to facilitate SNAP risk factor modification
for individual patients and practice populations eg around education for patients.
6.5 Practices seek the expertise of other service providers, eg ACCHSs, for implementation of
SNAP risk factor initiatives through general practice to high-risk populations.
Division and community level
6.6 Divisions develop and maintain locally/regionally based referral resources, eg directories of
providers to support referrals at the practice level.
6.7 Divisions work with practices and GPs to:
• develop awareness of and actively connect with community SNAP risk factor
modification programs; and
• facilitate referral of patients to these programs.
6.8 Develop appropriate patient confidentiality and informed consent guidelines/protocols for
use in general practices to facilitate referrals to other primary care providers.
6.9 Encourage and support regionally based collaborations between general practices and primary
care providers to facilitate integrated approaches to risk factor modification in individuals
or population groups.
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24. State level
6.10 Work with Divisions to develop state/regional level referral resources for GPs to assist in
linkages with others in the primary care sector to facilitate risk factor modification for
individuals or population groups.
National level
6.11 In consultation with Divisions, SBOs, GPCG, and State and Territory Governments ensure
information technology systems and software developed to facilitate SNAP risk factor
identification and management in general practice include provision for development of
electronic directories of services and programs and other tools to support referral to SNAP
risk factor modification programs and primary care providers.
6.12 Develop national policies, strategies explicitly encouraging linkages and communication
networks at all levels between GPs and GP organisations, allied health professionals,
ACCHS’s and their Affiliates and national peak body, and the population health sector.
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25. Outcome 7: Research and evaluation
Objective 7: Facilitation of research into appropriate evidence based
interventions, data collection and evaluation of integrated
approaches to SNAP risk factor identification and management in
general practice
Suggested activities or roles
GP consultation
7.1 GPs use evidence based patient information and interventions (using EBGs as a resource) in
consultations, taking into account the risk status of patients.
7.2 GPs and patients given opportunities to participate in SNAP risk factor research activities,
eg through clinical audit processes, trials of risk factor interventions, to increase skill levels
and contribute to the evidence base for integrated risk factor approaches in general practice.
GP practice
7.3 Practice staff participate in training on application of SNAP risk factor EBG.
7.4 Practices establish systems that support uptake of SNAP risk factor EBG by GPs, drawing
on support from Divisions or other support structures.
7.5 Practices install and train staff in the use of electronic information management systems to
support the collection of data for collation at practice, Division, state or national levels to
contribute to audit, monitoring, research and evaluation in SNAP risk factors, taking into
account patient privacy/consent issues.
Division and community level
7.6 Develop mechanisms to provide feedback to practices about practice populations including
comparisons with regional populations to assist GPs in their clinical practice.
7.7 Establish mechanisms between Divisions and regional population health providers for
collection and analysis of SNAP risk factor data for planning, policy development and research
at the regional level.
State level
7.8 Facilitate the collation and distribution of state level data on SNAP risk factors so that it
contributes effectively to state level planning and policy development by State Governments,
SBOs, Divisions, GPs and other population health providers.
7.9 State Governments, SBOs and NGOs ensure EBG developed at the state level are consistent
with the “Red Book” and other nationally agreed EBG.
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26. National level
7.10 Build the evidence base through research by:
• Analysis of the implications of the Report on the Relative Effectiveness of Population
Health Interventions in General Practice for SNAP risk factor interventions at the
national level and development of an implementation plan based on recommendations.
• Evaluation of activities implemented at all levels to facilitate uptake of the SNAP
Framework in general practice and implications taken into account in further
development/implementation of the Framework.
• Promotion of innovative approaches and research on integrated risk factor management
in general practice to build the evidence base of effective interventions in the Australian
context.
7.11 Develop Evidence Based Guidelines addressing SNAP risk factors that:
• are relevant to the general practice setting and take account of guidelines for EBG
development so that uptake in general practice is maximised;
• address evidence relating to patient lifestyle/behaviour change theory;
• provide consistent messages across related EBG, eg in tobacco, alcohol and other risk
factors, the “Red Book” and the Sharing Health Care Initiative;
• are regularly updated and maintain their currency;
• consider the health needs of high-risk population groups such as Aboriginal and Torres
Strait Islanders through consultative mechanisms;and
• are made available to all practices in Australia in electronic and hard copy formats.
7.12 Develop data collection systems to improve capacity for research and evidence based planning
through:
• modification of the BEACH data collection to support on-going data collection on risk
factors;
• establishment of systems to aggregate data at practice, Division/regional, state and
national levels;
• production of reports on aggregated data that are able to be used for regional, state and
national policy development and planning;
• consolidation of advice from GPs, population health academics, GPCG and NACCHO
on data collections and appropriate modifications of data collections, and research
principles to maximise usefulness at national, state and regional levels; and
• development of chronic disease risk factor surveillance and monitoring systems.
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28. List of partners for SNAP Framework
Aboriginal Community Controlled Health Consumers Health Forum and other
Services consumer organisations
Aboriginal Health Workers Continuing Medical Education providers
Academic Departments of General Practice Diabetes Australia and other diabetes related
Allied health peak bodies (eg pharmacy, non-government organisations
dieticians) Dieticians Association of Australia
Allied health providers eg nurses, Divisions of General Practice
physiotherapists, psychologists, dieticians, Drug treatment service providers
exercise physiologists
Enhanced Primary Care Initiative Reference
Australian Government Department of Groups
Health and Ageing: Ageing and Aged Care
Division, Health Services Improvement General practice Computing Group
Division, Information and Communications General Practice Memorandum of
Division, Medical and Pharmaceutical Understanding Group
Services Division, Office for Aboriginal and
General Practice Partnership Advisory
Torres Strait Islander Health, Population
Council
Health Division, Portfolio Strategies
Division, Primary Care Division and State General practitioners
Offices. Health Insurance Commission
Australian Network of Academic Public Joint Advisory Group on General Practice
Health Institutions and Population Health
Australian Cancer Society Local Governments
Australian Council for Health, Physical Medical software companies
Education and Recreation
NACCHO and State/Territory affiliates
Australian Divisions of General Practice
National Expert Advisory Committee on
Australian General Practice Accreditation Alcohol
Ltd and Board
National Expert Advisory Committee on
Australian Institute of Health and Welfare Tobacco
Australian Indigenous Doctors Association National Health Priorities Action Council
Australian Local Government Association and individual NHPA committees
Australian Medical Association National Health Priority Areas not identified
elsewhere
Behavioural medicine units
National Heart Foundation
Bettering the Evaluation And Care of Health
(BEACH) Consortium National Information Service of the General
Practice Evaluation Program
Cancer Councils
National Kidney Foundation
Carer Associations
National Medical Health and Research
Chronic Disease Alliance
Council
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29. National Population Health Strategies Royal Australian College of General
National Public Health Partnership (National Practitioners, (Vocational Training Program)
Strategies Coordination Working Group) Royal Australian College of Physicians
National Rural Health Alliance (Paediatrics and Child Health Division)
National Stroke Foundation Specific risk factor reduction programs
National Vascular Prevention Collaboration State Based Organisations of General
Practice Divisions
Other GP data networks
State Governments
Other GP organisations
State population health organisations other
Other NGOs and peak organisations than those already listed
PHERP Departments and other Academic Strategic Inter Governmental Forum on
Departments of Population Health Physical Activity and Health (SIGPAH)
Post Graduate Public Health Program for Strategic Inter Governmental Nutrition
Clinicians Consortium (PHEC) Alliance (SIGNAL)
Practice accreditation bodies University Departments of General Practice
Primary Care Providers other than those University Departments of Public/Population
already listed Health
QUIT counsellors, diabetes and other University Departments of Rural Health
educators
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